The distribution of ethanol in postmortem blood specimens.

Ethanol was determined by gas chromatography in a variety of tissues and body fluids secured at autopsy in 61 cases. The specimens tested included right and left heart blood, femoral blood, pericardial fluid, cerebrospinal fluid, vitreous humor, urine, stomach contents, and brain. Statistical analysis of the cases revealed no significant differences among the various blood sites tested. However, the variations in blood ethanol concentrations among the various sampling sites within each case were as follows: 40 cases showed differences of less than 25%; 16 cases revealed variability between 25% and 50%, 4 cases had differences exceeding 50%. In one case, satisfactory blood analyses could not be accomplished. The larger variances occurred especially in those instances in which stomach alcohol concentration was 0.50% or greater. In one case, the variability amongst the different blood sites exceeded 400% (femoral blood--0.043%, right atrium--0.070%, root of aorta--0.156%); the brain was 0.050%, and the stomach contents was 1.2%. For all 61 cases, variances in blood alcohol content among the different sampling sites in a single cadaver ranged from 1.8 to 428%.     

An unusual case of post-mortem redistribution of ethanol

We report an unusual case of post-mortem redistribution of ethanol in a woman diver who died by drowning in seawater. The ethanol concentrations were right heart blood 0.60 g/l, left heart blood 2.08 g/l, femoral venous blood 0.63 g/l, gastric contents 5.87 g/l, bile 0.83 g/l. The mechanisms of post-mortem redistribution of ethanol described in the literature, that is, early redistribution from the stomach or the lung parenchyma in the case of inhalation of gastric contents, are inadequate to account for the degree of variation observed between the measurements. We believe that this difference in concentration is explained by the presence of seawater in the pulmonary alveoli at the time of death.     

Complex suicide by ethanol intoxication and inhalation of fire fumes in an old lady: interdisciplinary elucidation including post-mortem analysis of congener alcohols

An 88-year-old woman committed suicide by drinking a toxic amount of highly concentrated alcohol and setting two rooms of her flat on fire. As there was not enough oxygen, the fire went out, however. At autopsy, no thermal lesions were found on the body, but soot depositions in the airways and a COHb value of 14% pointed to the inhalation of fire fumes. The ethanol concentration in femoral blood was 6.62 per mille. The gastric mucosa was fixed by the ingested alcohol and showed hardly any autolytic changes despite a post-mortem interval of five days. Congener analysis of the gastric contents and the femoral blood indicated the uptake of a fruit distillate or its foreshot.     

Interpretation of a 3,4-methylenedioxymethamphetamine (MDMA) blood level: discussion by means of a distribution study in two fatalities

The amphetamine derivative 3,4-methylenedioxymethamphetamine (MDMA, "Ecstasy" is a currently used or abused designer drug and fatalities are frequently encountered in forensic practice. However, the question remains open whether an MDMA blood level can be toxic or even potentially lethal. In order to provide insight in the interpretation of a detected MDMA concentration, the distribution of MDMA and its metabolite 3,4-methylenedioxyamphetamine (MDA) in various body fluids and tissues was studied and discussed in two different fatalities. Apart from peripheral blood samples (such as femoral and subclavian blood), various blood samples obtained centrally in the human body and several body fluids (such as vitreous humour) were examined. In addition, various tissues such as cardiac muscle, lungs, liver, kidneys, and brain lobes were analysed. In contrast to the peripheral blood levels, high MDMA and MDA levels were found in cardiac blood and the majority of the organs, except for the abdominal adipose tissue. The high concentrations observed in all lung lobes, the liver and stomach contents indicate that post-mortem redistribution of MDMA and MDA into cardiac blood can occur and, as a result, blood sampled centrally in the body should be avoided. Therefore, our data confirm that peripheral blood sampling remains "the golden standard". In addition, a distinct difference in peripheral blood MDMA concentrations in our two overdose cases was established (namely 0.271 and 13.508 microg/ml, respectively). Furthermore, our results suggest that, if a peripheral blood sample is not available and when putrefaction is not too pronounced, vitreous humour and iliopsoas muscle can be valuable specimens for toxicological analysis. Finally, referring to the various mechanisms of death following amphetamine intake, which can result in different survival times (e.g. cardiopulmonary complications versus hyperthermia), the anatomo-pathological findings and the toxicological results should be considered as a whole in arriving at a conclusion.     

Postmortem blood and vitreous humor ethanol concentrations in a victim of a fatal motor vehicle crash

A 20-year-old male was found on the passenger side of a small car after a collision with a semi-trailer truck. Postmortem blood, collected from the chest cavity, and vitreous humor samples were collected following harvesting of the heart and bones. Gas chromatographic analysis revealed a blood ethanol concentration of 0.32 g/dL and a vitreous humor ethanol concentration of 0.09 g/dL. The stomach was intact and full of fluid and food, but its contents were not collected. Possible explanations for the large difference between the two results include diffusion of ethanol from the stomach into the chest cavity, contamination of the blood sample prior to collection, and ingestion of a large quantity of ethanol shortly before death. This case demonstrates the importance of proper quality assurance procedures in collecting postmortem specimens and of collecting a vitreous humor sample for ethanol analysis in postmortem toxicology cases.     

Abnormally high alcohol concentration in the heart blood

A 46-year-old male alcoholic whose whereabouts had been unknown for about a month was found dead at the foot of a cliff 31 m deep. Fractures of the mandible, thorax and left patella were found at autopsy, but fatal injury to the brain or other organs was not observed. The alcohol distribution was 7.44 mg/g in the heart blood, 13.91 mg/g in the left thoracic cavity fluid and 1.88 mg/g in the urine. The high ethanol concentration in the heart blood was assumed to be mainly due to the diffusion of ethanol from the contents of the stomach and postmortem production of ethanol. It was decided that the cause of death was not acute alcohol intoxication but respiratory failure caused by fractures of the thorax.     

Morbus Fahr--considerations on a case of sudden death

This paper presents 21 cases related to cyanide intoxication by oral ingestion. Cyanide concentrations in biological specimens are especially different from the type of postmortem specimens, and very important in interpreting the cause of death in postmortem forensic toxicology. Besides the detection of cyanide in autopsy specimens, the autopsy findings were unremarkable. Biological samples (0.2mL or equal to less than 10μg of cyanide) were analyzed colorimetrically for cyanide. In a series of 21 cyanide fatalities, the concentration ranges (mean±SD) of cyanide in heart blood, peripheral blood and gastric contents were 0.1-248.6mg/L (38.1±56.6mg/L), 0.3-212.4mg/L (17.1±45.1mg/L) and 2.0-6398.0mg/kg (859.0±1486.2mg/kg), respectively. The ranges of the heart/peripheral blood concentration ratio and gastric contents/peripheral blood concentration ratio were 0.3-10.6 (mean 3.4) and 3.4-402.4 (mean 86.0), respectively. From the difference of cyanide concentration and the concentration ratio of cyanide in different types of postmortem specimens, the possibility of the postmortem redistribution of cyanide and death by oral ingestion of cyanide could be confirmed. We reported cyanide fatal cases along with a review of literature.     

Differences between multisite postmortem ethanol concentrations as related to agonal events

In a study of postmortem ethanol concentrations, blood was withdrawn from the right atrium, ascending aorta, and inferior vena cava. These samples, vitreous humor, and gastric fluid were analyzed in 307 autopsies, where a minimum blood ethanol concentration of 0.05% weight/volume (w/v) was present. Premortem, agonal, and postmortem events were reviewed in an attempt to account for differences in blood ethanol concentrations between sites. The agonal aspiration of vomitus having at least 0.80% w/v ethanol appears to be associated with an increase in aortic ethanol concentrations. We conclude that valid interpretation of postmortem ethanol concentrations must take into consideration the possible entry of ethanol into the pulmonary venous circulation via the respiratory system.     

Ethanol production by Candida albicans in postmortem human blood samples: effects of blood glucose level and dilution

We present two cases in which the ethanol concentration in blood samples taken after death continued to increase in the absence of any remarkable increase in n-propanol concentration. Species of bacteria and yeasts, including Candida albicans were isolated from these samples. We then examined whether C. albicans, the most common yeast in the general environment, was able to produce ethanol in human blood stored at room temperature. Ethanol production increased as the glucose concentration increased, indicating that C. albicans produced ethanol from the glucose. Our results also suggested that C. albicans produced ethanol more easily in blood diluted by intravenous infusions that included glucose than in undiluted blood. These findings are useful for the evaluation of postmortem ethanol production in subjects whose blood has been diluted by infusions with glucose. Furthermore, there was no quantitative relationship between the amount of n-propanol detected and the amount of ethanol production: n-propanol appears to be an unreliable index of putrefaction and postmortem ethanol production by C. albicans. It is possible for the blood ethanol level to be high and n-propanol not to be detected, even if the subject has not been drinking alcohol. We reconfirmed the necessity of immediately adding sodium fluoride to samples for ethanol analysis to prevent postmortem ethanol production.     

The redistribution of selected psychiatric drugs in post-mortem cases

The post-mortem redistribution of a number of psychiatric drugs was investigated. A portion of liver, the gastric contents and blood collected from heart and femoral sites was obtained from 13 cases and analyzed by liquid chromatography-mass spectrometry. Drugs detected included five selective serotonin reuptake inhibitors; venlafaxine, a serotonin/noradrenaline reuptake inhibitor; and risperidone, an atypical antipsychotic. Heart blood concentrations were significantly higher (3.4-fold on average) than those measured in femoral blood when results from all drugs were included together. The range for parent drug concentrations in these two blood specimens was 0.5-6.2. There was no significant correlation of the post-mortem interval, the liver concentration and content of drugs in the gastric contents to the heart:femoral blood concentration ratio. These data serve to demonstrate that variable increases in blood concentration occur post-mortem and limit the interpretative value of such toxicological data.     

Postmortem absorption of drugs and ethanol from aspirated vomitus--an experimental model.

Using human cadavers an experimental model was developed to simulate the agonal aspiration of drug- and alcohol-laden vomitus. By needle puncture, an acidified (N/20 HCl) 60-ml slurry of drugs (paracetamol 3.25 g, dextropropoxyphene 325 mg) and ethanol 3% w/v was introduced into the trachea. After 48 h undisturbed at room temperature, blood samples were obtained from ten sites. Ethanol and drug concentrations were highest in the pulmonary vessels in all five cases studied. Pulmonary vein mean ethanol was 58 mg% (range 13-130), paracetamol 969 mg/l (range 284-1934), propoxyphene 70 mg/l (range 11-168). Pulmonary artery mean ethanol was 53 mg% (range 10-98), paracetamol 476 mg/l (range 141-882), propoxyphene 29 mg/l (range 7.6-80). Ethanol and drug concentrations in aortic blood were higher than in the left heart and concentrations in the superior vena cava were higher than in the right heart, suggesting direct diffusion into these vessels rather than diffusion via the pulmonary and cardiac blood. Potential interpretive problems arising from this phenomenon can be avoided by using femoral vein blood for quantitative toxicological analysis.     

A comparison of post-mortem ethanol levels obtained from blood and subdural specimens

Post-mortem subdural ethanol levels have been proposed as a useful test in certain forensic cases involving head trauma, particularly when the time interval from injury to death may have caused a lowering of the blood ethanol concentration to insignificant or undetectable levels. This study of 75 autopsied persons from whom both blood and subdural ethanol levels were obtained, shows the usefulness of the subdural ethanol level, especially where there is a prolonged or unknown post-traumatic time interval. Use of such a test is recommended in these situations.     

A blood cyanide distribution study in the rabbits intoxicated by oral route and by inhalation

Blood cyanide concentration was determined in rabbits intoxicated orally or by inhalation. Experiments were carried out under urethane anaesthesia. In the inhalation experiments, rabbits inhaled a combustion product containing HCN via the tracheal cannula and in the oral studies animals were administered NaCN solution into the stomach. In addition to the carotid artery and jugular vein blood samples, postmortem samples were obtained from both sides of the heart and the descending vena cava. The arterial cyanide concentration in the inhalation group showed a close relationship with ventilation. After an initial rise, blood levels decreased a little, in some cases with transient apnea. At the last stage it again increased with gasping, reaching its maximal value. After ultimate apnea, the blood cyanide concentration declined. The blood cyanide values were higher in the oral group than in the inhalation group. The difference between the two groups became larger in the inferior order, the left heart blood--the right heart blood--blood in the descending vena cava. The left heart/right heart ratio of the inhalation group was significantly higher than that of the oral group (1.28+/- 0.28 vs. 0.95+/- 0.09). The coefficient of variation (c.v.) of the inhalation group was larger than that of the other group. Within the inhalation group, the left heart blood showed the largest c.v. values and this was probably due to redistribution of the cyanide by bloodstream after attainment of the maximal concentration.     

886例人心传导系统形态变异研究

探讨划分心传导系统 (CCS)变异与发育异常的界限。用本组建立的CCS检查法[1] ,连续切片 ,HE或Masson三色染色 ,光镜检查 ,对非心源性死亡组 (737例 )和心源性猝死组 (14 9例 )进行形态学及死因对比分析。结果显示 :(1)人CCS具有大小、位置和形态的先天性变异 ;(2 ) 4例心源性猝死者的房室结、房室束发育异常。房室束分叉部向室间隔膜部内移位、偏向于室间隔左侧、向左下侧移位 ,以及不足 1/2房室结移位至中心纤维体内、普通心肌移位至房室束或左束支内等应属变异 ;成年人胎儿型房室结及房室结全部移位至中心纤维体内或房室束完全分成 3束以上 ,房室束分叉部移位至三尖瓣根部应视为发育异常     

A fatal case of mercuric cyanide poisoning

A 57-year-old pharmacist was found dead 11 days after his disappearance. At the autopsy, samples of blood, urine, gastric content were obtained. Presence of ethanol, cyanide and mercury were detected in some samples. Cyanide and mercury were identified and quantified using high-performance liquid chromatography with diode array detector (HPLC) in fluorescence mode and ICP with mass selective detector (ICP-MS) respectively. Whole blood concentrations of ethanol was 1.72 g/L. Cyanide and mercury concentrations in whole blood were respectively 0.16 and 3.8 mg/L. Concentrations of cyanide (27 mg/L) and mercury (150 mg/L) in gastric contents prove a massive oral ingestion of mercuric cyanide or mercuric oxycyanide occurred. In this case report, the death was attributed to the combined toxicity of cyanide and mercury.     

Assessment of the acuteness of heroin deaths from the analysis of multiple blood specimens.

Data was compiled from 126 morphine-involved cases investigated by the Office of the Chief Medical Examiner, State of Maryland, USA. An investigation was conducted into whether comparison of morphine concentrations from a central and peripheral site could be used to determine whether a morphine death was acute or delayed. Fifty cases were identified as 'acute' because the urine free morphine concentration by radioimmunoassay (RIA) was less than 25 ng/mL; 76 cases were classified as 'random' because they had a urine morphine concentration greater than 25 ng/mL by RIA. The average heart blood to peripheral blood morphine concentration ratio in the acute deaths was 1.40. The average heart blood to peripheral blood morphine concentration ratio in the random deaths was 1.18. Because there was considerable overlap between the two groups of data, the authors conclude that it was not possible to predict 'acute' opiate intoxication deaths versus 'delayed' deaths when the only information available is heart and peripheral blood free morphine concentrations.     

氯氮平在家兔体内死后再分布规律研究

目的阐明死后48h内家兔体内氯氮平再分布规律,为相关法医鉴定工作提供借鉴。方法取家兔15只,随机分为5组,以氯氮平灌胃,分别于死后0、6、12、24、48h取心血、外周静脉血、尿液、肝组织检测氯氮平浓度。结果家兔死亡后心血、外周静脉血、肝脏氯氮平浓度不断升高,尿液氯氮平浓度不断降低;死后早期浓度变化率大于晚期浓度变化率。死后48h心血、外周静脉血、肝脏、尿液氯氮平浓度分别为死后0h各检材氯氮平浓度的418%、193%、154%和29%。结论死亡一段时间后,提取生物检材,检测出的氯氮平浓度并不能准确反映刚死时的实际浓度。     

Comparative study of ethanol levels in blood versus bone marrow,vitreous humor,bile and urine

Post-mortem ethanol levels in blood were compared to corresponding levels in rib bone marrow, vitreous humor, urine and bile. In forensic toxicology, a good correlation between blood and a tissue or body fluid is needed to estimate a blood alcohol concentration when blood is unavailable or contaminated. In this study, direct injection and headspace gas-chromatographic techniques were employed to quantitate the ethanol concentrations. Comparable findings by these two techniques showed a reproducibility of results. When the determined bone marrow ethanol levels were corrected for the lipid fraction, a consistent correlation could be established between ethanol levels in blood and bone marrow. The relationship (linearity and ratio range) between ethanol levels in blood and corrected levels in bone marrow was better than that between blood and vitreous humor, bile or urine. This study showed that blood ethanol levels can be predicted by extrapolating the corrected rib bone marrow ethanol level.     

Classification of digoxin concentrations in blood and tissues in cases under suspicion of poisoning

The clarification of a suspicion of poisoning at all times poses a problem to the forensic toxicologist, when a narrow margin of therapeutic safety and a low dosage coincide as in cases of digoxin poisoning. Statistical methods may serve as an aid. The post mortem digoxin concentration in the tissues of heart, kidney, liver and in blood of 45 patients who had received therapeutic daily doses and of 13 cases of fatal poisoning are compared. After logarithmic transformation of the individual concentration values a two modal distribution is obtained. There is one concentration calculated with equal probability of being classified to "therapeutic or toxic", as well as the probability of observing the "critical" concentrations of 400 ng digoxin/g cardiac tissue, 500 ng/g kidney and 250 ng/g liver after therapeutic dosing. Using the discriminant analysis each of the cases clearly falls into one of the two collectives "therapeutic" and "toxic", when taken as a separate observation. Concentration data of fatal poisonings taken from the literature are as successfully classified as the analytical results of some exhumed bodies under suspicion but not poisoned. As expected the power of discrimination increases with the number of parameters. Because of the relatively slow body distribution of digoxin the blood taken from peripheral vessels is of most important evidence.